IMPORTANT

To,

Mr.NOEL GEORGE SILVER

FLAT NO 2, SHREYAS APTS, 10TH CROSS, R B I COLONY,
VENUGOPAL LAYOUT, ANAND NAGAR, R T NAGAR,
BANGALORE 560024
Bangalore,Bangalore,Karnataka -560024
Mobile : 9845040237.

Dear Customer,

Re: Health Insurance Policy - P/141125/01/2019/005984

We are extremely thankful to you for your renewal instructions and payment of premium. We enclose the renewed
policy based on our records. We would request you to kindly study the renewed policy carefully and revert to us if
there is any discrepancy to enable us to attend to the same.

Kindly note that the above request is very important and if we do not hear anything from you within 15 days, we
would presume that the policy issued by us is in order and the contract is concluded.

We would like to mention that we have incorporated the name of the intermediary as indicated by you.

We wish you good health and we look forward to serve you in the days to come.

With kind regards,

Authorised Signatory

In case of a need for hospitalization, kindly prefer our network hospital (list is available in our website) for a quick
response to your claim request. Please stay in eligible room as stated in the policy, to avoid payment of
proportionate increased charges claimed by the hospitals, from your hand.

Sum insured of this Policy is meant for utilization till its expiry. Bearing this aspect in mind, we have no doubt, you
will choose appropriate hospital, room rent and treatment charges, etc.

Should you need any assistance, our customer care will be delighted to assist you, whose toll free no. is 1800-425-
2255/1800-102-4477.

However, the ultimate decision will be that of yours only.

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 STAR COMPREHENSIVE INSURANCE POLICY
Unique Identification No.IRDA/NL-HLT/SHAI/P-H/V.III/398/14-15
SCHEDULE

Policy No. : P/141125/01/2019/005984 Previous Policy No. : P/141125/01/2018/004628

Customer Code : AA0005293438 GSTIN : 29AAJCS4517L1ZU
Customer Name : Mr.NOEL GEORGE SILVER SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 7316414 Issuing Office Code : 141125
Proposer's Name : Mr.NOEL GEORGE SILVER Issuing Office Name : Branch Office - Jayanagar
Address : FLAT NO 2, SHREYAS APTS, Address : 221 1st Floor 9th Main Road 5th
10TH CROSS, R B I COLONY, block
VENUGOPAL LAYOUT, ANAND Jayanagar Bangalore 560041
NAGAR, R T NAGAR,
BANGALORE 560024
Bangalore,Bangalore,Karnataka-
560024
Phone No : 080 - 23542675/9845040237/. Phone No : 080- 4938 9999
E-mail Id : . E-mail Id : Jayanagar@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 30/06/2017 Fulfiller Code : SO141125

Date of Inception of first policy : 30/06/2017

Renewal Year : First Year
Receipt No : 1168006228 Intermediary Code : OL0000000026
Receipt Date : 18/07/2018 Name : M/S.Pramukh Health
Premium :Rs 14,275 /- Services Pvt. Ltd
CGST @9% : 1,285 /- SGST / UTGST @9% : 1,285 /-
Phone No : 080 - 41155655 / 41155877/
Stamp Duty :Rs 1 /- Total Premium :Rs 16,845 /-
E-mail Id : ops@phservices.in
Total Premium In Words : Rupees Sixteen Thousand Eight Hundred Forty Five Only
Period of Insurance : FROM 18/07/2018 00:00:00 TO : Midnight Of 17/07/2019

The limit of liability of Under Section 1(D), 1(G), 2, 3, 4, 5 & 7 are given in the schedule of benefits in the following pages.

Details of Insured Persons :

Section 1 Section 7
Inception
Age in Basic Sum Capital Sum Pre-existing Date
Sl. Name of the Insured Sex Date of Relationshi ID Card Bonus Disease/s
Yrs Insured Insured
no. Birth p with No (Rs.)
(Health) (Rs.) (Rs.)
Proposer
1 NOEL GEORGE SILVER M 12/04/1976 42 SELF 7316414-1 1500000 1500000 1500000 30/06/2017

PED : Diseases related to Respiratory System

Please check whether the details given by you about the insured persons in the proposal form are incorporated correctly in the policy schedule. If
you find any discrepancy, please inform us within 15 days from the date of receipt of the policy, failing which the details relating to the insured
person given in the policy schedule are deemed to have been accepted by you.
Warranted that in case of dishonor of premium cheque(s), the Company shall not be liable under the policy and the policy shall be void abinitio

For Star Health and Allied Insurance Company Ltd.

Entered by : SH19283

IRDAI Regn. No 129

Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in Authorised Signatory

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Attached to and forming part of Policy No : P/141125/01/2019/005984

(from inception).
Expenses relating to the hospitalization will be considered in proportion to the room rent stated in the policy.

Condition No. 4 regarding delay in payment of claim shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"
THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC.,
ATTACHED.
IMPORTANT
IN THE EVENT OF HOSPITALIZATION OF INSURED PERSON, INTIMATION SHOULD BE GIVEN TO THE COMPANY IMMEDIATELY,
HOWEVER, WITHIN 24 HRS FROM THE TIME OF ADMISSION.
Sector Classification :

Urban
Toll Free No: 1800 425 2255/1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522
"Consolidated Stamp duty paid vide G.O. Rt. No.5/306 dated 25.10.2017"

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 J P SILVER Mother 80 100

Schedule of Benefits

Section Description Maximum Benefit Rs available under the respective Section/s, subject to the
terms of the Policy Clause attached
For Section I - Sum Insured Option of 500000 750000 1000000 1500000 2000000 2500000
Ambulance Charges 2000 3000 3500 4000 4500 5000
1D Air Ambulance Charges NA 75000 100000 150000 200000 250000
1G Limit for Outpatient Medical Consultation 1200 1500 2100 2400 3000 3300
Normal Delivery 10000 20000 25000 25000 25000 25000
2 Delivery by Caesarean Section 15000 40000 40000 40000 40000 40000
New Born Cover 50000 100000 100000 100000 100000 100000
3 Outpatient Dental & Opthalmic Treatment 5000 5000 10000 10000 10000 10000
Hospital Cash Limit per day
4 Per occurrence - Limit 7 days 500 750 750 1000 1000 1500
Per annum - Limit 120 days
Health Check up
5 Limit per policy for every block of 3
completed claim free years payable after 5000 7500 7500 12000 12000 12000
renewal (Up to Rs )

For Star Health and Allied Insurance Company Ltd.

Entered by : SH19283

Authorised Signatory

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Attached to and forming part of Policy No : P/141125/01/2019/005984

Section 7 Accidental Death and Permanent Total Disablement

Benefits Percentage of the Capital Sum Insured
1. Death 100%
2. Permanent Total Disablement 100%
Total and Irrevocable loss* of
(i) Sight of both eyes 100%
(ii) Physical seperation of two entire hands 100%
(iii) Physical seperation of two entire foot 100%
(iv) One entire hand and one entire foot 100%
(v) Sight of one eye and loss of one hand 100%
(vi) Sight of one eye and loss of one entire foot 100%
(vii) Use of two hands 100%
(viii) Use of two foot 100%
(ix) Use of one hand and one foot 100%
(xi) Sight of one eye and use of one hand 100%
(xi) Sight of one eye and use of one foot 100%

In witness whereof the undersigned being authorised by and on behalf of the company has set his hand at Branch Office - Jayanagar on 18th
Day of July 2018.

For Star Health and Allied Insurance Company Ltd.

Entered by : SH19283

Authorised Signatory

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 TAX Invoice

Invoice No. : 29D168Y19P001028 Customer ID : AA0005293438

Invoice Date : 18/07/18 Policy No : P/141125/01/2019/005984
Recipient Supplier

GSTIN : - GSTIN : 29AAJCS4517L1ZU

Proposer's : Mr.NOEL GEORGE SILVER NAME : Star Health and Allied Insurance Co Ltd
Name - Branch Office - Jayanagar
Address : FLAT NO 2, SHREYAS APTS, Address : 221 1st Floor 9th Main Road 5th block
10TH CROSS, R B I COLONY, Jayanagar Bangalore 560041
VENUGOPAL LAYOUT, ANAND
NAGAR, R T NAGAR,
BANGALORE 560024
City : Bangalore,Bangalore,Karnataka- City : JAYANAGAR
560024
State : Karnataka State : Karnataka
Pincode : 560024 Pincode : 560 041
Client Category : IND Place of Supply : 29 - Karnataka

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% Total Invoice Value
SAC Service(s)
A B C=A-B D = C * IGST E=C F=C H = C + D + E+
Code
*CGST *UTGST or F
SGST

997133 Insurance Services 14275 0 14275 1285 1285 Rs. 16845

Total Invoice Value (in Figures) : Rs. 16845
Total Invoice Value (in Words) : Rupees: Sixteen thousand eight
hundred forty-five only
Amount of Tax Subject to reverse Charge : No

Important Note:

The invoice is issued as per Section 31 of the CGST Act

In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Star Health and Allied Insurance Co Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken.

E. & O.E
This is a digitally signed document and hence no physical signature is required

IRDAI Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

For Star Health and Allied Insurance Company Ltd.

Entered by : SH19283

Authorised Signatory

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